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Updated: Nov 11 2020

Acute Fatty Liver of Pregnancy

  • Snapshot
    • A 30-year-old G1P0 presents to the emergency room with her husband. She is pregnant with twins at 36 weeks gestation. Earlier that night, her husband noticed that she suddenly seemed more yellow. She then complained of right upper quadrant pain, nausea, and general feeling of malaise. She had not taken any medications. On exam, she is alert and oriented only to person, and she is found to have elevated liver enzymes, coagulopathy, and hypoglycemia. A hepatic ultrasound rules out trauma but doesn’t yield much more information. She is taken to the operating room for a cesarean section immediately for suspected acute fatty liver of pregnancy.
  • Introduction
    • Overview
      • acute fatty liver of pregnancy (AFLP) is a complication of pregnancy characterized by hepatic microvesicular steatosis and acute liver failure
  • Epidemiology
    • Incidence
      • rare
    • Demographics
      • pregnant women
    • Risk factors
      • nulliparity
      • multiple gestations
    • Pathogenesis
      • mechanism
        • thought to be due to mitochondrial dysfunction of fatty acid beta-oxidation, leading to accumulation of fatty acids within hepatocytes and liver dysfunction
  • Presentation
    • Symptoms
      • common symptoms
        • nausea and vomiting
        • malaise
        • right upper quadrant pain
        • upper gastrointestinal bleed
        • fulminant liver failure
        • sudden-onset jaundice
    • Physical exam
      • inspection
        • hypertension
        • altered mental status
        • jaundice
        • coagulopathy
  • Imaging
    • Hepatic ultrasound
      • indications
        • low sensitivity and thus not typically indicated
      • findings
        • decreased or diffuse attenuation
  • Studies
    • Serum labs
      • liver injury
        • ↑ AST/ALT
        • ↑ bilirubin
        • ↓ clotting factors
      • may have ↓ glucose
      • may have ↑ creatinine
      • normal acetaminophen level
      • negative viral serologies
    • Invasive studies
      • liver biopsy
        • indications
          • gold standard for diagnosis
          • not often utilized due to risk of hemorrhage
        • findings
          • pericentral microvesicular steatosis
          • minimal necrosis
  • Differential
    • Acetaminophen toxicity
      • key distinguishing factor
        • history of acetaminophen ingestion
        • elevation in AST/ALT are typically significantly higher
        • ↑ acetaminophen level
    • HELLP syndrome
      • key distinguishing factor
        • characterized by hypertension, hemolysis, elevated liver enzymes, and low platelets
  • Treatment
    • Medical
      • supportive care
        • indications
          • all patients
      • repletion of coagulation factors
        • indications
          • coagulopathy
    • Surgical
      • immediate delivery of fetus
        • indications
          • all patients; this is the only treatment
        • modalities
          • induction of labor
          • cesarean delivery
  • Complications
    • Maternal and fetal death
    • Acute liver failure
      • treatment
        • liver transplant
    • Acute renal failure
    • Encephalopathy
  • Prognosis
    • High risk of maternal and fetal mortality
    • After delivery, maternal prognosis is good
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